FAST1 FLOWS

By now, we’re hopefully all on intraosseus access if normal iv access is problematic. Most probably use the EZ-IO, which helped revolutionise io access by making it easy, fast and pretty reliable. But getting good flow can often be a problem. The FAST1 seems to change that.

Watch the video (in Norwegian), and watch the flow at 4:30. It’s not just dripping fast – it’s flowing! Without a pressure bag! Now, that’s impressive.

Special forces IO choice
The FAST1 sternal io needle has been around for a long time, but I’ve never had the chance to test one before now. And thus, I had settled with io access often giving mediocre flow rates, even with pressure bags. Enter the FAST1 sternum needle. This was tested with all sorts of other io needles by the Norwegian special forces. Cost is not an issue in a special forces setting. Weight/batteries can be an issue. But the biggest focus was on getting high flow rates. If one of these guys need fluids, they probably need it quickly and lots of it. The FAST1 came out ahead.

But HOW much better flow rates? Watch the video from a demonstration we did in our department. One anaesthetic registrar injecting the FAST1 on another registrar. Then hooking the io up to a bag of Ringer’s. At 4:30 you can see how the fluid flows freely. Not dripping – flowing! Without a pressure bag! I’ve never seen that with an io access before.

Short needle – High flow
The secret seems to be the very short needle on the FAST1. The needle’s inner diameter is 17G, but because it’s only about 1cm long, it doesn’t restrict flow much. The needle continues in a G14 plastic tube that connects to your giving set. This makes the FAST1 low profile, but – most importantly – high flow.

After this demonstration, it was decided we need the FAST1 in our trauma bay. Hopefully, after dodging a few bureaucratic hurdles, it will be there, next to the EZ-IO. This also made me want to share the demonstration, to see if you’re as impressed as I am. Any other input on io’s are most welcome.

10 Responses to FAST1 FLOWS

Impressive demonstration! Unfortunately my Norsk is too bad to understand very much. What about the pain when introducing it? Saw a few videos of Special Forces guys trying those themselves, but I wonder what your workmate told about the pain.

Well, as you can see in the video, he doesn’t even flinch as the needle goes in. However, he told me he’d rate the pain to 5-6 on the 1 to 10 pain scale, but as it was a very short lived burst, it wasn’t a big deal. It’s over before you realize it’s there.

What’s often rated more painful, is injecting through the IO. You’ll see in the video they flush through the needle with a low volume syringe to ‘clear’ the infusion area of ‘sludge’. Actually, he hits the head of the syringe driver hard to ‘shock flush’ it. But no great pain is noted here. He also injects a couple of ml lidocain/xylocain to take any pain on infusion. All in all, not very painful.

Thanks for your fast answer. I reallt guessed only spec ops sort of guys could stand that pain! 😉
Would you mind telling which hospital this was recorded at? I would really love to observe the work in that department next time I`m in Norway. 😉

One problem I can foresee with introducing FAST1 to civilian practice is having a firm enough thoracic cage to press against. In military practice the chest is generally well protected by body armour, whereas in civilian practice multiple rib and / or sternal fractures are not uncommon from the mainly blunt mechanisms. This could affect the firing of the device as you need a fair amount of pressure to cause the device to fire.

In military hospital (as opposed to pre-hospital) practice FAST1 is rarely used as we aim for a subclavian line instead.

Interesting points. I wonder how a flail chest would influence FAST1 insertion. I think it would be fine to use, but something to keep in mind. Sternal fracture would be a contraindication to io insertion there, but you might not know about the fracture at the time of insertion. Sternal fractures are relatively rare, but certainly not unheard of – I had two last month.

Also intersting on CVCs. So you go for a subclavian CVC in the trauma bay? We seldom go for CVCs at that early stage. In difficult access and critically bleeding patient, I will go for a big bore iv cannula or rapid infusion catheter in the external jugular because it’s quicker, safer and gives more flow. I have inserted a CVCs when patient bled out, but usually in the femoral – but that might be gone in military/IED trauma. I’d love to hear more about your use of CVCs in trauma, though.

As you say, always useful with another tool in the bag. Thanks for your comment.

With our current ‘typical’ injury pattern of multiple limb amputations or at the least extensive soft tissue damage to the limbs peripheral iv access is difficult hence the preponderance of IO devices.
Our standard trauma team set up is an airway anaesthetist and assistant, and a second anaesthetist to gain subclavian CVC access using a short, fat single or double lumen line generally 7 or 8.5Fr. This is then connected to a Belmont rapid infuser with two staff to feed it the shock packs.

We tend to avoid femoral vein due to the high number of pelvic fractures associated with blast injuries and pelvic binders being in place and the neck being collared.
There is also a thought that the subclavian vein is splinted open by its ligament out relationships and so in a hypo olefin state maybe easier to access.

Again, thanks for your comments. It’s always fascinating to hear how you do trauma in the war-zones, as the military is at the forefront of trauma management – and what can be used in civilian settings trickles over to us after a while.

Fantastic set-up for your trauma team. And with a short 7-8.5Fr CVC, I can see how you get good flows! That’s comparable to our RICs. And the big Belmont is a serious piece of kit. It must be great to have such a dedicated set-up when you’re dealing with war type injuries.

It seems like the JRAMC is now behind a paywall, but I’ll look into it once I get back to work. I might be able to access it from there.

Good set-up with a dedicated CVC man. It then makes good sense to insert a subclavian.

So, in the military, do you see similar flow rates of your FAST1 as in the video above, meaning you are happy with how it performs?

Got to read the article you linked to, thanks. Great stuff. I do love reviews with a practical rather than a theoretical/academic approach when covering interventions like this. The article is also sprinkled with pearls on iv access in trauma/resuscitation settings. Highly recommended for anyone working in these kinds of settings! Might have to make a post of it.

FAST1 seems to get good flow rates, somewhere near a 18G IV equivalent. Generally I would use a humeral EZ-IO in preference, decent flow rates, and sufficient for the contrast to be given through when we get to CT.

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About ScanCrit

A blog on anaesthesia, intensive care and emergency medicine. In-hospital and outside. Mostly focusing on the critically ill patient. Written by two Scandinavian senior anaesthetic registrars turned consultants.

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